Understanding of the Importance of Therapeutic Communication - Mr Smith Case Study Nursing Assessment Answer Answer

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Mr Smith Case Study Nursing Assessment Answer Answer

Patient Background:

Mr Smith is 72 years old and now lives alone. His wife, Joy, died two years ago. Mr Smith and his wife had three children, Doreen, Beth and Nelson. Doreen is a teacher and moved to New York. Beth is a community nurse and lives locally. Mr Smith was very close with his son, however Nelson died in an accident six months ago. Mr Smith, once an active and jovial man has been lonely since Joy and Nelson’s deaths. He used to play bowls but has withdrawn and has not been out with his mates lately. He has accepted his diagnosis of bowel cancer with resignation. The GP has noted that Mr Smith has had weight loss, decreased appetite and needs encouragement with fluid intake. Doreen is coming home from New York and she and Beth are going to look after Mr Smith on his discharge.

Past Medical History:

Mr Smith has a history of chronic obstructive pulmonary disease (COPD), osteoarthritis and type II diabetes (diet controlled, however Mr Smith stated “I only take my ‘sugar pill’ sometimes”). A recent colonoscopy resulted in a diagnosis of bowel cancer. Mr Smith was a smoker but hasn’t smoked for the last 10 years. Mr Smith uses a walking stick when mobilising due to an ankle fracture 15 years ago and he usually manages his ADLs independently.

Mr Smith’s usual medications are:

Metformin 500mg BD, paracetamol 1gm TDS, ibuprofen 400mg BD and salbutamol 4 puffs PRN.

Presenting situation:

Your partnered RN, Cameron, asks you to complete a set of vital signs at 14:00. You introduce yourself to Mr Smith and explain who you are and that Cameron has asked you to help look after him this afternoon. Mr Smith replies ‘Oh gosh, that Cameron, he’s got lots of questions. He was using words that I didn’t understand. I didn’t know what he was talking about. So, I’m not sure if I gave the right answers. I was getting a bit muddled. It was all a bit too much.’ You provide reassurance.

Mr Smith tells you he would like to sit on the toilet to try to open his bowels. You assist Mr Smith to sit up on the side of the bed in preparation to stand. He states he feels a little bit ‘weird’ and ‘woozy’. He says his mouth is ‘dry’ and he needs a drink. You ask him if it is alright to check his vital signs and you conduct an A to H Assessment. The results are:

A – Airway is patent

B – RR = 22 bpm, O2Sats = 95%

C – BP 90/55, PR – 120bpm

D – Level of consciousness (LOC) – Mr Smith is oriented to time and place, his pupils are equal and reactive to light (PEARL), he has equal strength in his upper limbs, his right leg is strong, however his left is a little weaker. Mr Smith states he has not got any new pain, just his normal arthritic pain, with a pain score of 3/10.

E – Temp - 37^oC. Mr Smith’s mouth is dry, his skin is dry and flaky. No wounds or skin breakdown.

F – Last voided at 09:00, BNO today

G – Blood Glucose Level (BGL) is 7.2mmol

H – previous documentation indicates his daughter will be visiting through the afternoon

You begin to run through the phases of the clinical reasoning cycle prior to speaking to Cameron to tell him your observations of Mr Smith.

• Develop clinical reasoning and critical thinking skills for use in clinical practice
• Develop an understanding of the importance of therapeutic communication in delivering person centred care.
• Identify factors that may contribute to safe medication practices
• Develop skills in reflective practice
• Access, critique and utilise academic and evidence-based resources and present their work in an academic style

1. Identify and discuss two factors that can contribute to safe medication practices
2. Outline the importance of effective therapeutic communication and how it relates to person centred care 
3. What have you learned from this assessment? What actions will you take into clinical practice as a result of what you have learned? 

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